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Medi-Cal Update

Part 1 - Program and Eligibility | June 2022

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1. Remittance Advice Detail Code 010: Denials for Duplicate Claims

A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi-Cal can result in the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.

Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a correction request from that provider.

Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records that may impact beneficiary share of cost, access to services and estate recovery.

For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:

Correspondence Specialist Unit
P.O. Box 13029
Sacramento, CA 95813-4029

For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.

2. Unsatisfactory Immigration Status Population in MCIP

Effective for dates of service on or after July 1, 2022, non-emergency and non-pregnancy-related services for beneficiaries with Unsatisfactory Immigration Status (UIS) are not eligible for Federal Financial Participation (FFP) through Med-Cal County Inmate Program (MCIP). Section 1903(v) (2) of the Social Security Act (SSA) prohibits states from claiming federal funding for the aforementioned services. Emergency and pregnancy-related services provided to UIS beneficiaries will continue to remain eligible for FFP.

Beneficiaries (with an UIS) are individuals who fall into at least one of the following groups:

  • Any individual who falls within a restricted scope Medi-Cal aid code. Restricted scope Medi-Cal aid codes are those aid codes that cover only emergency and pregnancy related services, and when needed, long-term care. FFP for these aid codes is limited to emergency and pregnancy-related services.

  • Any individual who falls within a full scope aid code who is receiving state funded full scope Medi-Cal because they have an UIS. FFP for individuals receiving state funded full scope Medi-Cal is also limited to emergency and pregnancy related services. Individuals with an UIS, who are receiving state funded full scope Medi-Cal, will fall into one of the following categories:

    • “Qualified” Non-Citizen (QNC) beneficiaries who are subject to and have not met the five-year bar.

    • Individuals who are Permanently Residing Under Color Of Law (PRUCOL).

    • Senate Bill 75 (Chapter 18, Statutes of 2015) beneficiaries.

    • Young Adult Expansion (YAE) beneficiaries (ages 21 through 25).

    • Trafficking and Crime Victims Assistance Program (TCVAP) beneficiaries. The TCVAP program is a cash and medical assistance program for eligible non-citizen victims of trafficking and other crimes. TCVAP beneficiaries are in the following aid codes: 2V, 4V, 5V and 7V. TCVAP beneficiaries in aid code 2V and 4V are 100 percent State funded. For individuals in aid codes 5V or 7V, FFP is available only for emergency and pregnancy-related services.

    • Effective May 1, 2022, Older Adult Expansion (OAE) beneficiaries (50 years of age or older).

3. Antiretroviral Ibalizumab-uiyk Injection Available for Managed Care Plans

Effective retroactively for dates of service on or after March 6, 2018, HCPCS code J1746 (injection, ibalizumab-uiyk, 10 mcg) is a noncapitated service for Managed Care Plans (MCPs) except for the following Health Care Plans (HCPs):

  • Cal MediConnect

  • Program of All-Inclusive Care for the Elderly (PACE)

  • Senior Care Action Network (SCAN)

  • Health Plan of San Mateo

  • CalOptima

HCPCS code J1746 is used to treat multidrug resistant HIV-1 in heavily treatment-experienced adults failing their current antiretroviral regimen.

lbalizumab-uiyk was available as a noncapitated·service for AIDS Healthcare Centers - Los Angeles for dates of service from March 6, 2018, to June 30, 2019.

Providers are encouraged to check the Medi-Cal website regularly for updates to the current list of contract drugs and MCP policy.

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6)

4. Healthy Families Checkwrite Decommissioned

Assembly Bill 1494, Chapter 28, Statutes of 2012, required Healthy Families (HF) subscribers to be transitioned into the Medi-Cal program and effectively terminated the standalone HF Program. These transitions occurred in 2013 and early 2014, and the Managed Risk Medical Insurance Board was disbanded shortly thereafter. However, HF checkwrite has continued to exist under the Medi-Cal program.

Medi-Cal is now formally decommissioning the remaining HF checkwrite process. This will entail:

  • Transitioning all uncollected HF accounts receivable to the Medi-Cal check write.

    • These amounts will be identifying on Medi-Cal Financial Summaries as State Children’s Health Insurance Program (SCHIP).

  • Releasing any erroneously unreleased SCHIP payments.

  • Closing all remaining HF accounts.

  • Redirecting all HF claims to Medi-Cal check write.

5. Fiscal Year 2021-2022 Two-Week Checkwrite Hold for Specific Provider Payments

Specific checkwrites scheduled in June for fiscal year 2021 – 2022 will be delayed until the start of fiscal year 2022 – 2023.

Medi-Cal funded fee-for-service programs scheduled with a warrant date of June 23, 2022, will be held until July 8, 2022. Checkwrites and payments to programs will be held during this time period:

  • Abortion

  • Medi-Cal

    • Child Health and Disability Prevention (CHDP)

    • Family Planning, Access, Care and Treatment (Family PACT) Program

Medi-Cal funded fee-for-service payments scheduled with a warrant date of June 30, 2022, will be held until July 8, 2022. Checkwrites and payments to programs will be held during this time period:

  • Abortion

  • California Children’s Services (CCS) (state-only)

  • Genetically Handicapped Persons Program (GHPP) (state-only)

  • Medi-Cal

    • CHDP

    • Family PACT

Payments made to the Every Woman Counts (EWC) program will be excluded from the checkwrite hold.

6. Medi-Cal Checkwrite Schedule Update for Fiscal Year 2022-2023

Effective for dates of service on or after July 1, 2022, the checkwrite schedule is updated for fiscal year 2022 through 2023. The schedule reflects warrant release dates and Electronic Fund Transfer (EFT) dates of deposit for all programs, including the following:

  • Abortion

  • California Children’s Services (CCS)

  • County Medical Services Program (CMSP)

  • Family Planning Access Care and Treatment (Family PACT) Program

  • Genetically Handicapped Persons Program (GHPP)

  • Medi-Cal

  • Other public health programs (Every Woman Counts [EWC])
Provider Manual(s) Page(s) Updated
Part 1 check (2, 3)

7. Walk-Up Claims Discontinued

Medi-Cal will no longer take walk-up claims delivery services. Providers will need to submit claims through mail or submit electronically. For more information about claim submissions and electric billing, visit the Welcome New Medi-Cal Providers page of the Medi-Cal Provider website.

Provider Manual(s) Page(s) Updated
Part 1 claim sub (8)

8. Medi-Cal Suspended and Ineligible Provider List is Updated

The monthly-updated Medi-Cal Suspended and Ineligible Provider List (S&I List) is available on the Suspended and Ineligible Provider List page of the Medi-Cal website.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities.

Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the OIG are subject to Medi-Cal suspension.

Welfare and Institutions Code (W&I Code), section 14043.61, subdivision (a), states, in relevant part, that “a provider shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs, to identify suspended, excluded, or otherwise ineligible providers.”

9. Medi-Cal Hotlines

Medi-Cal Hotlines

Border Providers 1-916-636-1200
DHCS Medi-Cal Fraud Hotline 1-800-822-6222
Telephone Service Center (TSC) 1-800-541-5555
Provider Telecommunications Network (PTN) 1-800-786-4346

For a complete listing of specialty programs and hours of operation, refer to the Medi-Cal Directory in the provider manual.

Mailing Address:
California MMIS Fiscal Intermediary
PO Box 13029
Sacramento, CA 95813-4029

Medi-Cal Fraud is Against the Law

Medi-Cal fraud costs taxpayers millions each year and can endanger the health of Californians. Help protect Medi-Cal and yourself by reporting violations today.

DHCS Medi-Cal Fraud Hotline: 1-800-822-6222

The call is free and you can remain anonymous. Knowingly participating in fraudulent activities can result in prosecution and jail time. Help prevent Medi-Cal fraud.

Stop Illegal Tobacco Sales

The simplest way to stop illegal tobacco sales to persons under the age of 21 is for merchants to check ID and verify the age of the tobacco purchasers. Report illegal tobacco sales to 1-800-527-5443. For more information, see the California Department of Public Health – California Tobacco Control Program website.

Free Smoking Cessation Resources

The California Smokers’ Helpline provides free help for quitting smoking in multiple languages. Services can be accessed via toll-free hotline 1-800-NO-BUTTS, text, online chat or mobile app. For more information, see the California Smokers’ Helpline website.

10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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